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        <jsp:param name="title" value="后台管理系统 - 用户管理"/>
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<!-- 头导航 -->
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<form action="${domain}/admin/first/e" method="post"  onsubmit="return checkForm()">
    <div align="center" width="1000px">
        <td><input name="oName" type="hidden" value="${oName}"></td>

        <h4>表6  2016年自费疫苗情况调查表</h4>

        <table border="1" cellspacing="0" cellpadding="0">
            <tr>
                <td >疫苗名称</td>
                <td>品规</td>
                <td>接种数量（人次）</td>
                <td>接种单价（元）</td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=firstE[0] value="甲肝疫苗" type="hidden">甲肝疫苗</td>
                <td><input name="firstE[1]"></input></td>
                <td><input name="firstE[2]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[3]" type="number"  step="0.01"></input></td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=firstE[4] value="乙肝疫苗" type="hidden">乙肝疫苗</td>
                <td><input name="firstE[5]"></input></td>
                <td><input name="firstE[6]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[7]" type="number"  step="0.01"></input></td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=firstE[8] value="乙脑疫苗" type="hidden">乙脑疫苗</td>
                <td><input name="firstE[9]"></input></td>
                <td><input name="firstE[10]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[11]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=firstE[12] value="流腮疫苗" type="hidden">流腮疫苗</td>
                <td><input name="firstE[13]"></input></td>
                <td><input name="firstE[14]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[15]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=firstE[16] value="HIB疫苗" type="hidden">HIB疫苗</td>
                <td><input name="firstE[17]"></input></td>
                <td><input name="firstE[18]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[19]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=firstE[20] value="23价肺炎疫苗" type="hidden">23价肺炎疫苗</td>
                <td><input name="firstE[21]"></input></td>
                <td><input name="firstE[22]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[23]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=firstE[24] value="水痘疫苗" type="hidden">水痘疫苗</td>
                <td><input name="firstE[25]"></input></td>
                <td><input name="firstE[26]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[27]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=firstE[28] value="轮状疫苗" type="hidden">轮状疫苗</td>
                <td><input name="firstE[29]"></input></td>
                <td><input name="firstE[30]" type="number"  step="0.01"></td>
                <td><input name="firstE[31]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=firstE[32] value="IPV活脊灰疫苗" type="hidden">IPV活脊灰疫苗</td>
                <td><input name="firstE[33]"></input></td>
                <td><input name="firstE[34]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[35]" type="number"  step="0.01"></input></td>
            <tr>
            <tr>
                <td><input readonly unselectable="on" name=firstE[36] value="流感疫苗" type="hidden">流感疫苗</td>
                <td><input name="firstE[37]"></input></td>
                <td><input name="firstE[38]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[39]" type="number"  step="0.01"></input></td>
            <tr>
                <td><input readonly unselectable="on" name=firstE[40] value="狂犬疫苗" type="hidden">狂犬疫苗</td>
                <td><input name="firstE[41]"></input></td>
                <td><input name="firstE[42]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[43]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[44] ></td>
                <td><input name="firstE[45]"></input></td>
                <td><input name="firstE[46]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[47]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[48] ></td>
                <td><input name="firstE[49]"></input></td>
                <td><input name="firstE[50]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[51]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[52] ></td>
                <td><input name=firstE[53] ></td>
                <td><input name=firstE[54]  type="number"  step="0.01"></td>
                <td><input name="firstE[55]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[56] ></td>
                <td><input name="firstE[57]"></input></td>
                <td><input name="firstE[58]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[59]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[60] ></td>
                <td><input name="firstE[61]"></input></td>
                <td><input name="firstE[62]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[63]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[64] ></td>
                <td><input name="firstE[65]"></input></td>
                <td><input name="firstE[66]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[67]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[68] ></td>
                <td><input name="firstE[69]"></input></td>
                <td><input name="firstE[70]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[71]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[72] ></td>
                <td><input name="firstE[73]"></input></td>
                <td><input name="firstE[74]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[75]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[76] ></td>
                <td><input name="firstE[77]"></input></td>
                <td><input name="firstE[78]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[79]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[80] ></td>
                <td><input name="firstE[81]"></input></td>
                <td><input name="firstE[82]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[83]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[84] ></td>
                <td><input name="firstE[85]"></input></td>
                <td><input name="firstE[86]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[87]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[88] ></td>
                <td><input name="firstE[89]"></input></td>
                <td><input name="firstE[90]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[91]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[92] ></td>
                <td><input name="firstE[93]"></input></td>
                <td><input name="firstE[94]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[95]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[96] ></td>
                <td><input name="firstE[97]"></input></td>
                <td><input name="firstE[98]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[99]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=firstE[100] ></td>
                <td><input name="firstE[101]"></input></td>
                <td><input name="firstE[102]" type="number"  step="0.01"></input></td>
                <td><input name="firstE[103]" type="number"  step="0.01"></input></td>
            </tr>
        </table>
        <p align="left">
            注：</br>
            1、疫苗范围包括免疫规划内收费疫苗与计划外疫苗，同一疫苗涉及多个剂型、厂商的，可作为不同品规分别填报。</br>
            2、接种单价包括接种费和疫苗费。</br>
            3、如本机构无某一疫苗的接种，请在对应的单元格中填横线。</br>
            4、表中没有列出的疫苗，请在空行中补充。</br>
        </p>
        <button type="submit" ><b>提交并进入下一表格</b></button>


    </div>

</form>
</body>
</html>